10 coverage checks to run before 'not covered' denials hit your January claims

The service was billed correctly, the note supports it and the payer has paid for it before. The claim still comes back marked "not covered." For the first time since Experian Health began its State of Claims survey in 2022, that is the denial reason respondents cite most: 53 percent put "services not covered" in their top three, ahead of frequently changing payer policies at 31 percent.

The survey of 204 health care finance, billing and claims staff comes from a vendor and doesn't break out results by practice size, so read it as a direction, not a benchmark. Still, 40 percent of respondents said 10 percent or more of their claims are denied, and only 30 percent recover 80 to 100 percent of denied revenue. Marketplace enrollment opened Nov. 1, Medicare open enrollment runs through Dec. 7 and most of those plan changes take effect Jan. 1.

One change moves in practices' favor. On Nov. 2, UnitedHealthcare posted the code lists behind its plan to drop prior authorization on more than 2,000 pediatric codes for members under 18 starting Dec. 1. The lists differ by plan and, for Medicaid, by state, so pediatric and family practices get a shorter queue only if they work the lists against their own claims. Here are 10 checks to run, starting there.